Larynx
ENT Clinic of Masaryk
university, Brno
Faculty St. Ann Hospital
LARYNX - function
Function: vital (respiration), social (phonation),
protective of lower airways (reflexes: closure of
aditus, glottis, cough reflex etc.)
Frontal
laryngeal
section
1. Aryepiglottic fold, 2. recessus piriformis, 3. vocal cord, 4. anterior
commisure, 5. thyroid cartilage, 6. cricoid cartilage, 7. thyroid gland, 8.
trachea. (Taken from Becker, Neumann, Pfaltz. Ear, Nose and Throat Diseases
1989)
Larynx
3 non-pair
cartilages
(thyroid, cricoid
and epiglottis)
3 pair cartilages –
arytenoidea,
corniculatae
(Santorini),
cuneiformes
(Wrisbergi)
Laryngeal muscles
Muscle moving larynx:
infrahyoid (sternohyoideus, -thyreoideus,
thyreoihyoideus, omohyoideus),
suprahyoid
Ones´own laryngeal muscles:
Abductores (open) – m. cricoarytenoideus post.
(POSTICUS)
Adductores (close) – cricoaryteoideus lat.,
arytenoideus transversus
Tensores (stretch) – m.cricothryeoideus (r.
ext. N. laryngici sup.), m. vocalis
Muscles moving aditus laryngis
m. aryepiglotticus, thyreoepiglotticus
Schema of function
of laryngeal
muscles
A-cartilago arytenoidea
C-cartilago cricoidea
T-cartilago thyroidea
1.-m. thyreoarytenoideus /vocalis/ "internus"
2.-m. cricoarytenoideus lateralis
3.-m. crycoarytenoideus posterior "posticus"
4.-m. arytenoideus transversus "transversus"
5.-m. cricothyreoideus
Laryngeal muscles
Muscle moving larynx:
infrahyoid (sternohyoideus, -thyreoideus,
thyreoihyoideus, omohyoideus),
suprahyoid
Ones´own laryngeal muscles:
Abductores (open) – m. cricoarytenoideus post.
(POSTICUS)
Adductores (close) – cricoaryteoideus lat.,
arytenoideus transversus
Tensores (stretch) – m.cricothryeoideus (r.
ext. N. laryngici sup.), m. vocalis
Muscles moving aditus laryngis
m. aryepiglotticus, thyreoepiglotticus
Internal ligaments and connective tissue
membranes (membrana fibroelastica
laryngis=quadrangularis + conus
elasticus
Conus elasticus
History of disorder
Breathing disorder
inspiratory stridor - stenosis localised upwards from bifurkation.
Symptoms of usage of auxiliary breathing muscles (retraction of
jugulum). There is longer inspirium as exspirium. General
symptoms - agitation with anxiety, loss of orientation, loss of
conscience, tachycardy, usually bradypnoe. Auscultation the
most noisy stridor above stenosis. Skin colour pale, then
cyanotic. Growing exhaustion, alarm face.
Voice disorder
Chrapot – trvající déle jak 14 dní u mužů rizikové skupiny
(kuřák nad 40 let věku) by měl být vyšetřen
otolaryngologem.
Dyspnoe
Respiratory Extrathoracal origin
Neuromuscular Psychogenic
Cardiovascular
Obstructive Restrictive Metabolic
Uremy
Hematologic
Toxic
Evaluation of dyspnoe
 Subjective scales
 (quasi) objective scales
0 10
no dyspnoe the vorst
dyspnoe
 no dyspnoe (0)
 dyspnoe after greater
physical labour than usually
(1)
 dyspnoe after usual physical
labour (2)
 dyspnoe at any physical
action (3)
 dyspnoe in no action (4)
Patofysiology of obstructive respiry
insufficience
 inspiratory dyspnoe
 stridor - 400-800 Hz, the most proximal stenosis, the lower
frequency is
 Involvement of auxiliary breathing muscles
 dysphony
 cogh, sometimes odynphagy.
Stage of compensation – prolongation of regular
inspiration, good blood supply, possible causal therapy
Stage of decompensation– mild tachypnoe, motoric
agitation, hyperkapny, anoxemy, respiratory acidosis, larynx
in anteflex position, anxiety, exhaustion. Hyperkapny leads
gradually to inhibition of breathing center
Stage of suffocation – air flow with turbulency,
decreased breath volume, reanimation is necessary
Obstructive respiratory insufficiency
1. Larynx and superior part of trachea „laryngeal“
dyspnoe
inspiratory stridor - stenosis localised upwards
from bifurkation. Symptoms of usage of auxiliary
breathing muscles (retraction of jugulum). There is
longer inspirium as exspirium. General symptoms agitation
with anxiety, loss of orientation, loss of
conscience, tachycardy, usually bradypnoe.
Auscultation the most noisy stridor above stenosis.
Skin colour pale, then cyanotic. Growing exhaustion,
alarm face.
2. Distal part of airways. Exspiratory stridor
- longer exspiration
Methods of investigation
 Inspection
 Palpation (crepitation, emphysema)
 Indirect laryngoscopy
 Direct laryngoscopy
 Microlaryngoscopy sec Kleinsasser
 Stroboscopy (high frequency movies, allowing
scientific analysis of the laryngeal function,
especially of the vocal cords
 Tomography
 CT
Transglottic cancer
spreading into
preepiglot. space,
subglottic spread
Congenital laryngeal
anomalies
Laryngomalacia – dyspnea,
dysphonia, dysphagia. Unusual
weakness of the supraglottic
laryngeal skeleton
Laryngoceles – lie within the larynx
in the vestibular fold – dyspnoe,
dysphonia
Atresia and membranes
Laryngitis acuta (restricted x
diffused)
Abscesus epiglottidis
Acute supraglottic laryngitis -
epiglottitis
 Hemophilus
influenzae
 inspiratory stridor
 dysphagia
 Antibiotic
treatment
 steroids
 tracheal intubation
 tracheostomy
Acute subglottic laryngitis
 Viral infection
 Rapid growth at night
 cough
 inspiratory stridor,
inspiratory dyspnea
 steroids, sedation,
ATB,
 Mikroclima (steam
inhalation)
Angioneurotic swelling of larynx
Laryngitis chronica
Diphtery
Laryngitis chron. hyperplastica
Polypus laryngis
Microlaryngoscopy
sec.
Kleinsasser
Polypus plicae vocalis l.dx.
Polypus plicae vocalis l.dx.
LARYNGITIS CHRONICAOEDEMA
REINCKE
Oedema laryngis
Papilomatosis laryngis, HPV
virosis
Intubation injury,
granulomas
Noduli cantatorii
vocal abuse, dysphonia, pain on speaking
• in voice proffesionals
• microlaryngoscopy
• strict voice rest
Cystis epiglottidis
Ca in situ bilat
Ca spino plicae voc. l.sin. T1
Ca spino plicae voc. l.sin. T2
Ca spino plicae voc. l.sin. T3
Ca spino sinus piriformis
Ca glottis
Disorder of laryngeal motivity
Seeman-Rosenbach rule – in insidious toxic
influence on recurrent nerve - first
damaged fibers phylogeneticly younger
(for m. posticus)
Laryngeal injury – symptoms,
diagnosis
 Dyspneu
 Dysphonia
 Bleeding – not very extensive
 Dysphagia – in connection to injury of
pharyngeal and eosophageal muscles
Hematoma of
right
vocal cord
Fractura of laryngeal skeleton
Laryngeal fracture
with a mucosal
hematoma and
dislocation of
the arytenoid
Laryngeal fracture , neck
emphysema
External layngeal injury, first
physician aid
 Anti- shock treatment
 care for airway
 Management of bleeding
Light injury (blunt trauma) conservative
treatment-
1) antihistaminics, corticosteroids,
antibiotics, analgetics, oxygen
2) cold compress on neck
3) in dyspnoe – coniotomy, intubation
Tracheotomy
Indication for tracheotomy
„Classic“ – to bridge stenosis caused by
inflammation, tumor, foreign body, injury,
palsy
„Prophylactic“ – if we suppose possible
stenosis (big surgery, swelling, bleeding,
irradiation…)
„Anestesiologic“ long term intubation of
patient (prophylaxis of intubation injury,
aspiration; reduction of dead space in
airway, suction…etc.)
Tracheotomy
Position in tracheotomy
Skin section – horisontal or
vertical
Thyroid gland isthm
resection
Trachea opening
Punction, dilatation
tracheotomy - Ciaglia (1985)
PDT – Griggs (1990)
Translaryngeal tracheotomy Fantoni
(1993)
Complication in tracheotomy
During surgery bleeding,
dyspnoe, lost of orientation,
Early post surgery
emphysema, embolism,
mediastinální emfyzém,
pneumothorax, inflammation
bleeding, nekoresponduje otvor
v průdušnici a na kůžiproblémy
s výměnou kanyly .
Late post surgery stenosis